MAJOR DEPRESSIVE DISORDER

PAUL SORISIO · 2026 · Case ID: A26029050

MIXED

Summary

The veteran served from October 1978 to April 1979, with subsequent National Guard and Reserve service until September 1999. The veteran appealed the denial of service connection for an acquired psychiatric disorder, claimed as depression, and the remand of the issue of service connection for hypertension. The Board reviewed evidence of record as of April 2021, excluding later submitted evidence which the veteran may submit via a Supplemental Claim. For the psychiatric disorder, the Board found no competent evidence of a diagnosed mental health condition or treatment during service, and the service treatment records were consistently negative for mental health issues. The veteran's testimony regarding an in-service incident and family history of mental illness was noted but could not be considered due to the evidentiary limitations. The Board denied service connection for the psychiatric disorder. For hypertension, the Board found the March 2021 VA opinion inadequate because it relied on post-service records and did not adequately address evidence suggesting the condition may have manifested during service or within one year of separation. The case is remanded for a new VA opinion to determine if hypertension first manifested during active service or within one year after separation, considering specific blood pressure readings from service and post-service examinations.

Rationale

No competent evidence of diagnosed mental health condition during service; Service treatment records negative for mental health issues; Veteran's testimony regarding in-service incident not considered due to evidentiary limitations

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210510-158314

Full Decision Text

Citation Nr: A26029050
Decision Date: 03/31/26 Archive Date: 03/31/26

DOCKET NO. 210510-158314
DATE: March 31, 2026

ORDER

Service connection for an acquired psychiatric disorder, claimed as depression, is denied.

REMANDED

The issue of service connection for hypertension is remanded.

FINDING OF FACT

At the time of the decision on appeal, there was no evidence of a diagnosed mental health disability or any indication that the claimed disability could be related to an event in service.

CONCLUSION OF LAW

The criteria for service connection for an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 1978 to April 1979, with National Guard and Reserve service from September 1978 to September 1999.

This matter comes before the Board of Veterans' Appeals (Board) from an April 2021 rating decision.

In his May 2021 VA Form 10182, the Veteran elected the Hearing docket. He testified at a Board hearing on August 12, 2024. Therefore, the Board may only consider the evidence of record as of April 19, 2021, the date of the rating decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. §?20.302(a). If the Veteran submitted evidence that was added to the record after April 19, 2021, and before the Board hearing on August 12, 2024, or more than 90 days after the Board hearing, the Board did not consider it.

The Board notes that evidence was added to the claims file during a period of time when new evidence was not allowed. The Board, however, may not consider this evidence in the present decision. 38 C.F.R. § 20.300. Nevertheless, the Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service connection for an acquired psychiatric disorder, claimed as depression, is denied.

The Veteran seeks service connection for depression. See fully developed claim from April 15, 2020.

At the Board hearing, the Veteran testified that he started mental health treatment in 2001. He referenced an in-service incident that resulted in him being sent for a mental health evaluation. He mentioned that there is a history of mental health disorders in his family, to include depression and schizophrenia, and suggested that his condition may have preexisted service.

At this point, it should be noted that the decision on appeal characterized the Veteran's claim as one of service connection for depression. In July 2023, while the present appeal was pending, the Veteran submitted a claim that included the issue of service connection for schizophrenia. This claim was denied in a November 2023 rating decision. The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). Based on the Veteran's hearing testimony, the Board finds that, notwithstanding the November 2023 decision, the present claim encompasses all current mental health disabilities, to include schizophrenia.

Since the above rating decision on appeal, VA and private treatment records showing recent treatment for depression and schizophrenia have been associated with the claims file. This evidence, as explained above, cannot be considered, as it was not received during the applicable, open evidentiary window. In the case of the VA treatment records, these records show treatment since September 2021, after the decision on appeal. There is no indication that the Veteran received VA treatment prior to the decision on appeal. The record shows that the AOJ requested any VA treatment records pertaining to the Veteran. These requests, however, resulted in a negative response.

Turning to the evidence properly before the Board in an open evidence window, a review of service treatment records does not show any evidence of mental health treatment during either active or inactive service. Rather, multiple examinations, up until 1994, are consistently
This evidence, as explained above, cannot be considered, as it was not received during the applicable, open evidentiary window. In the case of the VA treatment records, these records show treatment since September 2021, after the decision on appeal. There is no indication that the Veteran received VA treatment prior to the decision on appeal. The record shows that the AOJ requested any VA treatment records pertaining to the Veteran. These requests, however, resulted in a negative response.

Based on the evidence of record at the time of the decision on appeal, the Board finds that service connection for an acquired psychiatric disorder is not warranted. Significantly, there is no competent evidence of a diagnosed mental health condition or complaints or treatment during active service. As such, VA's duty to provide a VA examination was not triggered. The Board acknowledges that the Veteran, at the Board hearing, reported mental health treatment as well as an unspecified incident in service. As mentioned, this evidence was not of record at the time of the April 2021 rating decision on appeal; therefore, it cannot be the basis for the finding of a pre-decisional duty-to-assist error. Furthermore, the Veteran is not competent to establish a current diagnosis, as this requires testing and specialized expertise, to include application of the DSM-5, that he has not been shown to have. See 38 C.F.R. § 4.125(a). Additionally, the Veteran's report of an in-service incident leading to a mental health evaluation is not supported by service treatment records, which are consistently silent regarding any mental health issues during both active and inactive service. The Board fins these service treatment records are more probative than the Veteran's vague assertion of an in-service incident that revealed mental health issues.

As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable and the claim for service connection for an acquired psychiatric disorder is denied. Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021).

REASONS FOR REMAND

The issue of service connection for hypertension is remanded.

The Veteran seeks service connection for hypertension. See fully developed claim from April 15, 2020.

The decision on appeal determined that the Veteran has a diagnosis of hypertension, per a March 2021 VA examination. The Board see no reason to disturb this favorable finding and is bound by it. 38 C.F.R. § 3.104(c).

At the 2024 Board hearing, the Veteran testified that he was diagnosed with hypertension around 1980, adding that he has been taking hypertension medication since that time. The Veteran separated from active service in April 1979.

In contrast, at the March 2021 VA examination, the Veteran reported that he was diagnosed with hypertension in 1990 and started medication treatment in 1991.

The examiner opined that the Veteran's hypertension was at least as likely as not incurred in service. The examiner's rationale was that service treatment records were positive for a diagnosis of hypertension with treatment on a February 1991 periodic examination. The Board finds this rationale is problematic because it is based on service treatment records dated more than 10 years after the Veteran's period of active service.

Service treatment records show blood pressure readings of 120/72, 118/70, and 120/74 at the September 1978 enlistment examination. An examination from March 1979, one month before separation from active service, shows a blood pressure reading of 122/82. Thereafter, an October 1983 examination shows a blood pressure reading of 150/90. Notwithstanding these readings, the first time that hypertension is documented in service treatment records is in a February 1991 examination, which notes "hypertension under control with medication."

The Board takes judicial notice that a systolic pressure of 130 or higher, or a diastolic pressure of 80 or higher is indicative hypertension. See American Heart Association, "Understanding Blood Pressure Readings," at https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. In view of this, the Board finds that there is an indication that the Veteran's hypertension may have first manifested in active service or within one year after separation from active service.

As the March 2021 VA opinion was based on a period
readings, the first time that hypertension is documented in service treatment records is in a February 1991 examination, which notes "hypertension under control with medication."

As the March 2021 VA opinion was based on a period of inactive service and since it did not address the evidence suggesting that the Veteran's hypertension may have first manifested in active service or within one year after separation from active service, the Board finds that the March 2021 VA opinion is inadequate. The AOJ's failure to obtain an adequate opinion is a pre-decisional duty-to-assist error that must be corrected via remand. 38 C.F.R. § 20.802(a).

This matter is REMANDED for the following action:

Obtain a medical opinion as to whether the Veteran's hypertension first manifested in active service or within one year after separation from active service.

The examiner must review the claims file to become familiar with the Veteran's relevant medical history. Then, please provide a response to the following:

(a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's hypertension first manifested during his period of active service (from October 1978 to April 1979)?

(b.) If not, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's hypertension (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service?

**Please pay attention to the following: (1) an examination from March 1979, one month before separation from active service, shows a blood pressure reading of 122/82, and (2) an October 1983 examination shows a blood pressure reading of 150/90.**

All opinions must show adequate consideration of all relevant evidence, both lay and medical, and be supported by a complete medical rationale. In other words, the examiner must provide a medical answer to the question posed. Indeed, the rationale for each opinion must go beyond generalized statements. There must be some discussion of the facts and the medical principles involved in the Veteran's specific case for the opinion to be deemed adequate. While the absence of documentary evidence can be considered, such absence should not be the sole or main reason for ruling out a nexus. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training).

If the examiner determines that an in-person VA examination is needed, then such an examination should be provided.

Paul Sorisio

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board P. López, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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